Endocrine Surgery Practice Questions

Q: A patient presents with a sudden increase in the size of a thyroid swelling accompanied by pain. What is the most likely cause?

Hemorrhage within the cyst. ### Explanation **Correct Option: A. Hemorrhage within the cyst** The clinical triad of **sudden increase in size**, **pain**, and **tenderness** in a pre-existing thyroid nodule is a classic presentation of **hemorrhage into a thyroid cyst** or a degenerate nodule. This occurs because the rapid expansion of the cyst stretches the thyroid capsule, which is richly innervated with sensory nerves, leading to acute localized pain. **Analysis of Incorrect Options:** * **B. Malignant change:** While thyroid cancers (especially Anaplastic carcinoma) can grow rapidly, they are typically painless and present as a hard, fixed mass. Pain is a late feature associated with local invasion, not a sudden onset symptom. * **C. Nodular goiter:** This refers to a multinodular goiter (MNG), which usually progresses slowly over years. It is generally painless unless a specific complication like hemorrhage or secondary malignancy occurs. * **D. Colloid goiter:** This is a benign, diffuse enlargement of the thyroid due to accumulation of colloid. It is a chronic, painless condition and does not present with sudden acute changes. **Clinical Pearls for NEET-PG:** * **Management:** The initial management for a painful, hemorrhagic cyst is **Fine Needle Aspiration (FNA)**. This is both diagnostic and therapeutic, as it relieves the pressure and pain immediately. * **Anaplastic Carcinoma:** If a patient presents with a rapid increase in size *without* pain but with symptoms like hoarseness or dysphagia, suspect Anaplastic Carcinoma. * **De Quervain’s Thyroiditis:** Another cause of painful thyroid is Subacute Granulomatous Thyroiditis, but this is usually associated with systemic symptoms (fever, malaise) and elevated ESR, rather than a localized "swelling" that suddenly enlarges.

Q: What is the most common cause of respiratory distress after thyroidectomy?

Laryngeal edema. **Explanation:** Respiratory distress following thyroidectomy is a critical surgical emergency. While multiple factors can contribute, **laryngeal edema** is statistically the **most common cause** of post-operative airway obstruction. **1. Why Laryngeal Edema is Correct:** Laryngeal edema typically results from trauma during endotracheal intubation, surgical manipulation of the trachea, or venous/lymphatic congestion following the removal of a large goiter. It leads to narrowing of the glottic aperture, causing inspiratory stridor and respiratory distress, usually manifesting within the first few hours post-surgery. **2. Analysis of Incorrect Options:** * **Bilateral Recurrent Laryngeal Nerve (RLN) Palsy:** This is the **most serious** cause of immediate airway obstruction (due to the vocal cords remaining in the paramedian position), but it is rare compared to edema. * **Cervical Hematoma:** This is the most common cause of **tension-related** airway distress. It causes venous congestion and secondary laryngeal edema rather than direct tracheal compression. It is a surgical emergency requiring immediate bedside evacuation. * **Hypoparathyroidism:** (Note: Option D says Hyperparathyroidism, which is incorrect). Hypocalcemia resulting from hypoparathyroidism can cause **laryngospasm** (Tetany), but this typically occurs 24–72 hours post-operatively, not immediately. **Clinical Pearls for NEET-PG:** * **Most common cause overall:** Laryngeal edema. * **Most common cause of "Tension" distress:** Reactionary hemorrhage (Hematoma). * **Management of Hematoma:** Immediate opening of the wound at the bedside (do not wait for the OR). * **Tracheomalacia:** Consider this if the patient has had a long-standing, large goiter causing pressure atrophy of tracheal rings. * **Unilateral RLN injury:** Presents as hoarseness, not respiratory distress.

Q: Minimally invasive video-assisted thyroidectomy can be performed in all of the following conditions EXCEPT:

Prior neck surgery. **Explanation:** Minimally Invasive Video-Assisted Thyroidectomy (MIVAT), popularized by Miccoli, is a technique used to perform thyroid surgery through a small incision (usually 1.5–2 cm) with the aid of an endoscope. **Why "Prior neck surgery" is the correct answer:** Prior neck surgery or neck irradiation is a **strict contraindication** for MIVAT. Previous surgery leads to the formation of dense adhesions and loss of normal anatomical planes. This increases the risk of injury to the recurrent laryngeal nerve and parathyroid glands, making the limited visualization and restricted maneuverability of the video-assisted approach unsafe. **Analysis of Incorrect Options:** * **Benign solitary nodule:** This is the most common indication for MIVAT. As long as the nodule size is within limits (typically <30–35 mm), it is easily managed. * **Thyroid volume <25mL:** Small thyroid volume is a primary selection criterion. Large glands cannot be safely delivered through the small MIVAT incision. * **Follicular neoplasm:** Low-risk malignancies and follicular neoplasms (where the diagnosis of malignancy is uncertain pre-operatively) are suitable for MIVAT, provided the nodule size is small. **NEET-PG High-Yield Pearls:** * **Incision size:** 1.5 to 2 cm (compared to 6-8 cm in conventional surgery). * **Inclusion Criteria:** Nodule diameter ≤ 35 mm, total thyroid volume < 20-25 mL, and no evidence of thyroiditis or lymphadenopathy. * **Contraindications:** Large goiters, previous neck surgery/radiation, locally invasive malignancy, and Hashimoto’s thyroiditis (due to increased vascularity and friability). * **Advantage:** Better cosmetic outcome and reduced postoperative pain.

Q: A 50-year-old male presents with complaints of easy fatiguability, dyspnea, and neck swelling. On examination, a specific sign is observed. What is the appropriate management for this condition?

Surgery via a transcervical approach. **Explanation:** The clinical presentation of easy fatigability, dyspnea, and neck swelling in an older male suggests a **Retrosternal Goiter (RSG)**. The "specific sign" alluded to is likely **Pemberton’s Sign** (facial congestion and inspiratory stridor upon raising both arms), which indicates thoracic inlet obstruction. **1. Why Option C is Correct:** The definitive management for a symptomatic retrosternal goiter is surgical excision. Despite the extension into the mediastinum, **>90% of retrosternal goiters can be safely removed via a transcervical (neck) approach**. This is because these tumors typically derive their blood supply from the **inferior thyroid arteries** in the neck, allowing the surgeon to ligate the vessels and "deliver" the gland upward into the cervical incision. **2. Why Other Options are Incorrect:** * **Option A:** A transthoracic approach (sternotomy or thoracotomy) is reserved for rare cases (<5-10%), such as primary mediastinal goiters (supplied by intrathoracic vessels), malignancy invading mediastinal structures, or failed cervical delivery. * **Option B:** Radioactive iodine is generally ineffective for large, compressive multinodular goiters and may cause acute swelling (radiation thyroiditis), worsening respiratory distress. * **Option D:** TSH suppression does not significantly shrink large, established retrosternal goiters and delays definitive treatment for obstructive symptoms. **Clinical Pearls for NEET-PG:** * **Definition:** A goiter is considered retrosternal if >50% of its volume is below the thoracic inlet. * **Most Common Site:** Anterior mediastinum (85-90%). * **Pemberton’s Sign:** A classic high-yield physical finding for RSG or Superior Vena Cava Syndrome. * **Imaging Gold Standard:** CT scan (without contrast is preferred if RAI therapy is planned, though contrast is better for anatomical mapping).

Q: Complications of hemithyroidectomy include all of the following, except?

Hypocalcemia. **Explanation:** The correct answer is **Hypocalcemia**. **1. Why Hypocalcemia is the correct answer:** Hypocalcemia occurs due to accidental removal or devascularization of the parathyroid glands. There are four parathyroid glands (two on each side). In a **hemithyroidectomy**, only one lobe of the thyroid is removed, leaving the two contralateral parathyroid glands intact. These remaining glands are sufficient to maintain normal calcium homeostasis. Therefore, clinically significant hypocalcemia is a complication of total or subtotal thyroidectomy, but not hemithyroidectomy. **2. Analysis of incorrect options:** * **Wound Hematoma:** This is a potential complication of *any* neck surgery. A tension hematoma can cause life-threatening airway obstruction and requires immediate bedside evacuation. * **Recurrent Laryngeal Nerve (RLN) Palsy:** The RLN runs in the tracheoesophageal groove on both sides. Even in a unilateral procedure, the nerve on the operative side is at risk during dissection, leading to hoarseness of voice. * **External Branch of Superior Laryngeal Nerve (EBSLN) Palsy:** This nerve lies close to the superior thyroid artery. Damage during ligation of the superior pole vessels (on the operative side) results in loss of high-pitched voice and vocal fatigue. **NEET-PG High-Yield Pearls:** * **Most common cause of hypocalcemia post-thyroidectomy:** Accidental injury to parathyroid glands or their blood supply (Inferior Thyroid Artery). * **Chvostek’s and Trousseau’s signs:** Clinical indicators of latent tetany due to hypocalcemia. * **Nerve most commonly injured:** EBSLN (due to its proximity to the superior thyroid artery). * **Nerve injury causing "Bovine Cough":** Unilateral RLN palsy. * **Emergency Management:** For post-op respiratory distress due to hematoma, the first step is to **open the wound sutures at the bedside** to relieve pressure.

Question 1

A patient presents with a sudden increase in the size of a thyroid swelling accompanied by pain. What is the most likely cause?

Accepted Answer

Hemorrhage within the cyst

Answer

Malignant change

Answer

Nodular goiter

Answer

Colloid goiter

Question 2

What is the most common cause of respiratory distress after thyroidectomy?

Accepted Answer

Laryngeal edema

Answer

Bilateral recurrent laryngeal nerve palsy

Answer

Cervical hematoma

Answer

Hyperparathyroidism

Question 3

Which of the following imaging modalities is least sensitive in the preoperative evaluation of parathyroid adenoma in primary hyperparathyroidism?

Accepted Answer

MRI

Answer

Sestamibi scintigraphy

Answer

Sestamibi SPECT

Answer

Ultrasound

Question 4

Minimally invasive video-assisted thyroidectomy can be performed in all of the following conditions EXCEPT:

Accepted Answer

Prior neck surgery

Answer

Benign solitary nodule

Answer

Thyroid volume <25mL

Answer

Follicular neoplasm

Question 5

Which nerve is most likely to be involved in malignant spread and thyroid surgery?

Accepted Answer

Both recurrent laryngeal nerve and superior laryngeal nerve

Answer

Recurrent laryngeal nerve

Answer

Superior laryngeal nerve

Answer

Internal laryngeal nerve

Question 6

A 50-year-old male presents with complaints of easy fatiguability, dyspnea, and neck swelling. On examination, a specific sign is observed. What is the appropriate management for this condition?

Accepted Answer

Surgery via a transcervical approach

Answer

Surgery via a transthoracic approach

Answer

Radioactive iodine ablation

Answer

Levothyroxine for TSH suppression

Question 7

A patient is diagnosed with a prolactinoma encircling the carotid artery. What is the best line of management?

Accepted Answer

Transsphenoidal surgical resection

Answer

Wait and watch

Answer

Radiotherapy

Answer

Combination therapy

Question 8

A female with a history of recurrent renal stones presented with severe bone pain. Laboratory findings are indicative of primary hyperparathyroidism secondary to parathyroid hyperplasia. What is the recommended treatment?

Accepted Answer

Removal of all parathyroid glands leaving a 50 mg tissue remnant

Answer

Removal of all four parathyroid glands

Answer

Calcitonin

Answer

Enlargement of parathyroid glands

Question 9

A patient with long-standing multinodular goitre develops hoarseness of voice, and the swelling undergoes a sudden increase in size. What is the likely diagnosis?

Accepted Answer

Follicular carcinoma

Answer

Papillary carcinoma

Answer

Medullary carcinoma

Answer

Anaplastic carcinoma

Question 10

Complications of hemithyroidectomy include all of the following, except?

Accepted Answer

Hypocalcemia

Answer

Wound hematoma

Answer

Recurrent laryngeal nerve palsy

Answer

External branch of superior laryngeal nerve palsy

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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